Men in the Arena – Application | Youth Service International

Personal Information

Name*

First Last

Mother's Name*

Father's Name*

Address*

Street Address City State ZIP Code

Home Phone Number*

Cell Phone Number

Phone Number of Parent (for emergency use)*

Email Address of Applicant*

Email Address of Parent*

Date of Birth*

Education

School Currently Attending*

Grade Point Average*

Extracurricular Activities*

College Attending Next Year*

If unsure, put your first choice.

Expected Major*

Miscellaneous

Medical Insurance Company*

Medical Insurance Group Number*

Medical Insurance Policy Number*

Medical Insurance Phone Number*

Electronic Signature for Medical & Photo Release*

As the parent or legal guardian of the participant identified on this registration, I hereby delegate authority to the Directors of "Men in the Arena" to arrange whatever medical treatment they deem necessary for him during the activity. Also, I hereby authorize and consent to the use and reproduction by YSI staff or an authorized agent or assignee of any and all photographs taken of the above-named applicant for the purpose of promoting YSI programs, without any compensation to me. All film, together with any prints, shall constitute property of YSI, solely and completely.

Reference*

Who recommended this program to you?

Comments

Please include any dietary restrictions or medical conditions.

College Expectations*

What are you most excited about for college? What are you most apprehensive about?